There are disparities in copayment policies throughout Europe, and much of the variation reflects how deregulated or nationalized the health service is in each country. In the United Kingdom, the bulk of the more than 400,000 cataract surgeries performed each year are done in National Health Service (NHS) institutions. These are often high-volume centers structured in a hierarchical system with trainees conducting much of the work. There are a few independent organizations that bid to do NHS work and are paid a tariff fee of approximately £700 per case. Most patients will not be reimbursed any additional amount for a toric implant, even where there is a medical need such as high cylinder.
Our Department of Health permits a combination of NHS and private care, but not in the same episode. The choice of a multifocal IOL is specifically cited in an NHS guidance document as an example of an instance in which patient copayment is not permitted.1 Neither can supplementary diagnostic tests be charged to the patient as an extra at consultation.
My view is that refractive cataract surgery is in a class of its own, and to accomplish this well and reliably requires a whole set of processes that includes highly skilled teams, sophisticated diagnostics, experience, and knowledge. Along with all this, considerable time is required to help prospective patients understand the implications of a multifocal lens, among them being the need for neural adaptation. Additionally, the treating center must have access to a facility to address patients with spherical and/or astigmatic refractive surprises. The additional cost of the multifocal IOL pales in comparison with the resource costs of the above, and all these costs must somehow be recovered.
Furthermore, judging by my observations of patients seeking second opinions after unsatisfactory treatment in the NHS with toric IOLs, allowing copayment for multifocal IOLs could pose considerable risk to the reputation of these lenses.
I am aware of lobbying efforts by the ophthalmic industry to EU regulators to ensure that all copayment policies are harmonized across all EU countries. This is a slippery slope for the relevant ophthalmic companies, that are, in my view, just inviting headline news of the wrong kind. An example of this occurred in the United Kingdom earlier this year, which has been bad not only for the company involved but also for the whole refractive lens industry.
I personally do not believe that toric IOLs should be considered a premium option for patients with 2.00 D or more of cylinder. However, multifocals IOLs with or without a toric component, because of patient expectations and the reasons described above, certainly are premium and must remain so. Permitting copayment for multifocal IOLs will result in a host of issues that will just cause harm to ophthalmic care in the United Kingdom. That is not to say it should never happen. If the NHS were to reduce the phenomenal bureaucracy required to be a provider to NHS patients and permit a free market in terms of the level of patient copayment—although there would still be considerable risk—competition would improve, along with provision of quality care.
Sheraz M. Daya, MD, FACP, FACS, FRCS(Ed), FRCOphth
• Director and Consultant Surgeon, Centre for Sight, East Grinstead, United Kingdom
• Chief Medical Editor, CRST Europe
• sdaya@centreforsight.com
